Primary tumours of the calcaneus. Are you experiencing other symptoms besides heel pain, such as fever, numbness, or swelling? Causes of heel pain also include: Achilles tendinitis; Achilles tendon rupture; Bone tumor; Bursitis (joint inflammation) Haglund's deformity; Heel spur; Osteomyelitis (a bone infection) Paget's disease of bone; Peripheral neuropathy Mild swelling around the tendon and morning stiffness in the heel and calf are also often experienced. Several conditions can cause foot and heel pain. There are several common causes of heel pain. In other instances, resting can help to eliminate the most severe pain until you are able to see your doctor or a podiatrist. Get useful, helpful and relevant health + wellness information. Orthotics. Tarsal tunnel syndrome caused by an uncommon ossicle of the talus: A case report. Fill a paper cup ¾ of the way with water and freeze it. 3. He specializes in spinal deformity and complex spinal reconstruction. doi: 10.7759/cureus.820, Causes of Heel Pain and Treatment Options, Ⓒ 2020 About, Inc. (Dotdash) — All rights reserved, Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Having an eating disorder, like anorexia or bulimia, Inability to walk comfortably on the affected side, Heel pain that occurs at night or while resting, Heel pain that persists beyond a few days, Swelling or discoloration of the back of the foot, Signs of an infection, including fever, redness, warmth, Where is your pain located? Many acute Achilles tendon ruptures are treated by placing the limb in a cast with the foot in equinus (toes pointing down). Heel pain is a common symptom that be a sign of many different conditions. Understanding Diabetic Foot Infection and its Management. It is not uncommon for some parts of our body to begin to grow in an abnormal manner. Sign up and learn how to better take care of your body. Heel pain may occur as a result of a broken bone in the foot. Plantar fasciitis occurs when too much pressure on your feet damages the plantar fascia ligament, causing pain and stiffness. We need to get around, and unfortunately … In addition, peripheral neuropathies associated with diabetes, alcohol abuse, or a vitamin deficiency can cause diffuse foot and heel pain.. Approaches to treat heel pain vary, and it is very important that the cause of the pain is understood before beginning a treatment regimen. Medically reviewed by Eva Umoh Asomugha, M.D. Long walks, in particular, can be tiring and our feet can be in agony after a day’s work, especially if we are wearing uncomfortable shoes. As with any injury, patients should seek medical advice before beginning any therapy. The following are common treatment approaches for Achilles tendonitis: Bursitis means an inflammation of a bursa, a sac that lines many joints and allows tendons and muscles to move easily when the joint is moving. If the person experiences severe pain or the injury does not get better in a few days, the person should seek medical care. There are, however, a few common, identifiable causes. Heel pain usually affects the underside or back of your heel. 2010;49(3 Suppl):S1-19. What Is Causing Your Achilles Tendon Pain? This pain occurs in the back of the heel, not the underside of the heel. Diabetes Metab Syndr. 2011;23(2):148-55. doi:10.1097/BOR.0b013e3283422cf5, Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Between 30 and 40 percent of the general population has a "heel spur" (on X-ray) and yet, there is no pain. The upside is that most solutions are fairly simple—rest, ice packs, and footwear modifications—that you can do at home without any hassle. One of the top causes of heel pain is plantar fasciitis, this is damage to a ligament that holds your heel to your toes. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. Common factors that can lead to plantar fasciitis are shoes without adequate support, heavy work demands, obesity, running, and abnormal foot mechanics (the way a person’s feet and ankle move to support the weight of our body). Swelling on the bottom of the heel People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they have been sitting for long periods of time. In the heel, bursitis may cause bruise-like pain usually at the back of the heel. If the pain is found at the back of the heel, in the achilles or toward the base of the achilles (the long cord that extends from your calf to your heel bone), then it is likely achilles tendinitis. Your symptoms might also give you an idea of what's causing your heel pain. Looking for help with a foot or ankle problem? Tu P, Bytomski JR. If your heel hurts, see your primary care doctor or foot and ankle orthopaedic surgeon right away to determine the cause and get treatment. More About Us. The pain of Haglund's syndrome is felt at the back of the heel and may be associated with limping and signs of inflammation like swelling, warmth, and redness. As the soft tissue surrounding the bony bump at the back of the heel gets irritated, bursitis may develop. https://orthoinfo.aaos.org/en/diseases--conditions/heel-pain. Policy. (Nighttime pain is more common with nerve-related sources of pain, as well as with tumors.). Am Fam Physician. There is no arch pain with this condition. CORONAVIRUS: DELAYS FOR ROUTINE SURGERIES, VISITOR RESTRICTIONS + COVID-19 TESTING. The papules are benign and only cause pain in less than 10 percent of cases., The cause is unknown, although experts suspect the papules may result from a hard heel strike during walking. 2011;35(4):507-13. doi:10.5535/arm.2011.35.4.507. The pain is usually the worst with the first few steps after awakening, although it can also be triggered by long periods of standing or when you get up after sitting. Podiatry Tips Day 229 - Dr Brandt R Gibson discusses the other causes of Heel Pain besides Plantar Fasciitis. doi: 10.1503/cmaj.121963, Tu P, Bytomski JR. Although heel pain sometimes is caused by a systemic (body-wide) illness, such as rheumatoid arthritis or gout, it usually is a local condition that affects only the foot. We do not endorse non-Cleveland Clinic products or services. Advertising on our site helps support our mission. Common Causes Of Heel Pain: 1. The severe, stabbing, or throbbing pain of plantar fasciitis is felt on the bottom of the heel and occurs upon weight-bearing after rest, such as when taking your first steps in the morning or when standing up after prolonged sitting.. In the heel, bursitis may cause bruise-like pain usually at the back of the heel. American Orthopaedic Foot and Ankle Society. Rest. Phys Sportsmed. Reviewed: Dr. Gromatzky. Read on to learn more about the causes, treatment, and prevention of heel pain. Injuries, sprains, fractures, pinched nerves, and wear and tear on the heel pad are common causes of heel pain. Read more about the causes of heel pain. 2013 Dec 10;185(18):E847. Patient education: Heel and foot pain (caused by plantar fasciitis) (Beyond the Basics). Symptoms include pain and stiffness in the back of the ankle close to the heel, especially when walking and bearing weight. Cause #2: Haglund’s Deformity. Sports Health. 2013;185(18):E847. Rarely, the Achilles tendon ruptures; this typically occurs as a result of engaging in a vigorous type of physical activity where the foot pivots suddenly (as in basketball or tennis). Back Of Heel Pain [Causes, Symptoms & Best Home Treatment] Back of heel pain [walking or running] The most common causes: #1) Achilles Tendonitis, #2) Heel Spurs #3) Retrocalcaneal Bursitis & #4)Haglund’s Bump! Some causes of heel pain are more serious than others. Radiographics. Management of plantar fasciitis in the outpatient setting. The sinus tarsi, referred to as "the eye of the foot," refers to the space on the outside of the foot between the ankle and heel bone. Cleveland Clinic is a non-profit academic medical center. 2. Stretching. See your GP or a podiatrist (foot problems specialist) if you’ve had persistent heel pain for a number of weeks and it hasn't cleared up. Use a night splint (a type of brace that holds the foot and ankle in the proper position and provides a light stretch of the Achilles/calf). Use an in-shoe orthotic device -- this may be an over-the-counter or custom device prescribed by a podiatrist, physician, or physical therapist -- to keep the foot stable and control excess foot motion. Causes. Plantar fasciitis is inflammation of the ligament that runs the length of the foot, commonly caused by overstretching. Pain that increases over a period of months 5. Heel pain is an extremely common complaint, and there are many potential causes, ranging from conditions that affect the actual heel bone, like a bruise or stress fracture, to conditions that affect structures near it, like plantar fasciitis or Achilles tendonitis. Heel Pain Types. Arthritis can also cause pain in the heel. If your pain occurs with weight-bearing activities, do you notice it first thing in the morning after rest (as in plantar fasciitis) or later in the day after activity (as in heel pad syndrome)? Finally, heel pain sometimes arises because the foot does not absorb shock as it should. 2016;57(4):168-70. doi:10.11622/smedj.2016069, Li HY, Hua YH. We are foot doctors & we see this problem get better almost every day. Typically, the presence or absence of a “heel spur” is not significant. Dealing with joint pain can cause major disruptions to your day. Signs of an infection, including fever, redness, warmth 6. Ma DL, Vano-galvan S. Piezogenic pedal papules. Additional causes include shoes with poor footbeds, arthritis, nerve entrapment, and abnormal walking positions and gait. Heel pain in the morning is a common sign of plantar fasciitis, but there are also other conditions that may cause this type of pain. Look: One of the top causes of heel pain is plantar fasciitis, this is damage to a ligament that holds your heel to your toes. Curr Opin Rheumatol. As with any injury, patients should seek medical advice before beginning any therapy. Repeated stress on the heel bone eventually leads to a break.. 2015;6(4):380-6. doi:10.5312/wjo.v6.i4.380, Hong CH, Lee YK, Won SH, Lee DW, Moon SI, Kim WJ. Your doctor and physical therapist will determine the best treatments for you. If you are unsure of your diagnosis, or how severe your condition is, be sure to seek medical advice before beginning any treatment plan. Regardless, your doctor can help you figure out what's causing the discomfort and craft a treatment plan that will help your specific situation. Bone Joint Res. Plantar Fasciitis is one of the most common recurring tendonitis injuries that active people will have to deal with. Medical Expert. The following are not common causes, however may cause heel pain symptoms and should not be overlooked. Clin Podiatr Med Surg. Bone and tissue tumours, like osteoid osteoma, are rare and are less likely than the above injuries to be causing the pain. Vaishya R, Agarwal AK, Azizi AT, Vijay V. Haglund's Syndrome: A Commonly Seen Mysterious Condition. While blood tests are not commonly ordered for the diagnosis of heel pain, your doctor may order one or more laboratory studies if she suspects or wants to rule out a particular condition. This is the most common cause of pain in the heel. Does your pain occur with weight-bearing activities or while at rest? Helgeson K. Examination and intervention for sinus tarsi syndrome. This causes a deep, aching pain felt in the middle of the heel that worsens with weight-bearing activity. Heel pad atrophy may present with diffuse plantar heel pain, especially in older patients who are obese. Here are some definite signs that you should be evaluated by a doctor: 1. Heel pain that persists beyond a few days 4. Baxter’s nerve entrapment can also happen at the bottom of the heel. Alfredson versus Silbernagel exercise therapy in chronic midportion Achilles tendinopathy: study protocol for a randomized controlled trial. It … Some common treatments are listed here—but keep in mind, not all of these are appropriate for every condition. 2017;20(2):87-89. doi:10.1016/j.cjtee.2017.01.002, American Academy of Orthopedic Surgeons. For instance, for plantar fasciitis, your doctor may recommend wearing splints at night to keep your foot straight. World J Orthop. Learn about the top 10 causes of heel pain when standing or walking. 2007;28(1):20-3. doi:10.3113/FAI.2007.0004, Sahu RL. Heel pain is most often caused by plantar fasciitis, a condition that is sometimes also called heel spur syndrome when a spur is present. They should be able to diagnose the cause of your heel pain by asking about your symptoms and medical history and examining your heel and foot. Inability to walk comfortably on the affected side 2. Approaches to treat heel pain vary, and it is very important that the cause of the pain is understood before beginning a treatment regimen. Heel pain is usually caused by overuse. Although almost any boy or girl can be affected, children who participate in sports that require a lot of jumping have the highest risk of developing this condition. Other common causes of heel pain may be: heel bursitis — inflammation of the back of the heel, the bursa (a fibrous sac full of fluid) stress fracture — this can be caused by repetitive stress, strenuous exercise, sports or heavy manual work. Nonsteroidal anti-inflammatory medications (NSAIDs) are commonly prescribed for heel pain caused by problems such as plantar fasciitis, Achilles tendonitis, a heel pad bruise, Haglund's syndrome, heel bursitis, heel pad syndrome, and sinus tarsi syndrome. Heel pain is one of the most common complaints of patients with foot and ankle disorders. The Most Common Reasons Your Feet May Hurt. Thank you, {{form.email}}, for signing up. Iontophoresis is a treatment that uses an electric current to deliver dexamethasone to the affected area to reduce inflammation. Wall leans (remain flat footed with knee fully extended and your foot pointed slightly inward, then lean toward the wall, slowly stretching the calf muscles and Achilles tendon) are a good way to stretch the Achilles tendon. Overuse of the heel is most often the cause of heel pain among other numerous causes. Plantar Fasciitis is closely associated with heel pain that occurs upon taking your first steps in the morning, or when getting up after a prolonged period of being seated. Advertising on our site helps support our mission. Management of achilles tendon injury: A current concepts systematic review. Apply the ice directly to the heel and arch area and move around in a circular fashion for approximately 5 minutes or until the skin feels numb. If you are unsure of the cause of your symptoms, or if you do not know the specific treatment recommendations for your condition, seek medical attention. Any other unusual symptoms Here are some of the causes, symptoms, and treatments of this issue, as well as some preventive tips. Heel pain has many causes. 2016;8(10):e820. 10 Causes of Heel Pain. Plantar fasciitis or heel spur syndrome is the tissue swelling over the sole of the foot. Besides severe heel pain, some people report hearing a "pop" or "snap" when the tendon tears.. For more acute causes of heel pain, such as a heel bruise, avoiding the precipitating activity—for example, take a few days off jogging or prolonged standing/walking—may be all you need to feel better. 2010;27(3):431-41. doi:10.1016/j.cpm.2010.04.004, Podolsky R, Kalichman L. Taping for plantar fasciitis. The goals of the following treatment approaches are to decrease inflammation and pain, increase flexibility, reduce excessive stress on the plantar fascia, and promote healing of the fascia. Arthritis, foot pain and shoe wear: current musculoskeletal research on feet. Usually we feel acute pain or an ache that comes as a result of a strain or injury.The pain is usually caused by any physical exercise which puts the heel under pressure, certain muscles being very stiff or unsuitable footwear. Percutaneous planter fasciitis release under local anesthesia: A prospective study. Other causes of plantar heel pain include calcaneal stress fractures (progressively worsening pain after an increase in activity or change to a harder walking surface), nerve entrapment or neuroma (pain accompanied by burning, tingling, or numbness), heel pad syndrome (deep, bruise-like pain in the middle of the heel), and plantar warts. If left untreated, these tiny tears and injuries gradually erode the Plantar Fascia’s ability to … If you experience pain, common causes of heel pain include: Heel spurs Plantar and medial heel pain: diagnosis and management. Common causes of heel pain include obesity, ill-fitting shoes, running and jumping on hard surfaces, abnormal walking style, injuries and certain diseases. Plantar Fasciitis is one of the most common recurring tendonitis injuries that active people will have to deal with. Shock wave therapy (strong sound waves) may be tried to reduce pain and promote healing of this condition. Sometimes, cortisone—a steroid that reduces inflammation—may be injected into the heel to ease the pain temporarily (for a few weeks, usually). 2018;97(25):e11008. Interestingly, they are a characteristic skin finding in people with the connective tissue disease Ehlers-Danlos syndrome., Rarely, an infection of the heel bone (called osteomyelitis) may cause pain—although, unlike most other sources of heel pain, the pain from an infection of the heel bone is usually constant. Reviewed: Dr. Gromatzky. 2015;28(1):1-6. doi:10.3233/BMR-140485, Habets B, Van cingel REH, Backx FJG, Huisstede BMA. Plantar heel pain causes the majority of mechanical heel pain cases. J Am Acad Orthop Surg. For Achilles tendonitis, your doctor may refer you to a physical therapist who uses a specialized exercise program called the Alfredson protocol, which focuses on eccentric loading of your Achilles tendon., Depending on the cause of your heel pain, various foot supports may be recommended by your doctor.. 2000;20(2):333-52. doi:10.1148/radiographics.20.2.g00mc09333, Thomas JL, Christensen JC, Kravitz SR, et al. An X-ray of the heel may be ordered to diagnose certain conditions like a stress fracture of the heel, Haglund's syndrome, heel spur, or bone tumor. There are also photos of heel spurs that can occur to the bottom of your heel (plantar fascia insertion) and the back of your heel (Achilles tendon insertion). Walking can be hard work. doi:10.7759/cureus.820, Pękala PA, Henry BM, Pękala JR, Piska K, Tomaszewski KA. Kucuksen S, Karahan AY, Erol K. Haglund syndrome with pump bump. 9500 Euclid Avenue, Cleveland, Ohio 44195 |. Abnormalities of the skin, nerves, bones, blood vessels, and soft tissues of the heel can all result in pain.Because of walking and daily movement, we are always at risk for injury or trauma to the heel area. Heel pad syndrome is due to thinning of this fat pad that results from trauma, such as the consistent pounding of the foot in marathon runners or pressure put on the foot due to obesity. Likewise, heel wedges or shoe orthotics may be recommended for the treatment of Achilles tendonitis. Heel pain – not to be missed! Baxter nerve compression (Figure 2) 2. Considering this, it's probably no surprise that there are many potential causes of your heel pain that may be suspected. Of the 17 potential heel pain causes, the two most common culprits are plantar fasciitis and Achilles tendinitis. Heel pain is generally the result of faulty biomechanics (walking gait abnormalities) that place too much stress on the heel bone and the soft tissues that attach to it. Your physician and physical therapist will determine the best treatment for you. Swelling or discoloration of the back of the foot 5. Haglund's Syndrome (With or Without Bursitis), Haglund's syndrome, also referred to as "pump bump," occurs when a bony prominence at the back of the heel rubs against rigid shoes.. In certain cases, though, additional tests like imaging studies and/or blood tests are warranted. 2017;18(1):296. doi:10.1186/s12891-017-1656-4, Riskowski J, Dufour AB, Hannan MT. 2018;97(2):86-93. Plantar fasciitis … Tarsal tunnel syndrome — a pinched nerve; heel pad wear and tear; osteomyelitis — infection of the bone; How is heel pain … Depending on the exact source of pain, prevention strategies may slightly differ. Cureus. The most common causes are plantar fasciitis, Achilles tendonitis and arthritis.If you have heel pain that persists, you should see a doctor or physiotherapist. Surgery. Do not worry if you're not sure what the problem is. 1. Massage with ice. The causes of heel pain are many and varied. Read our. Plantar fasciitis is inflammation of the ligament that runs the length of the foot, commonly caused by overstretching. Other causes of heel pain must also be considered, even if you've experienced this discomfort and gotten one of the above diagnoses before: Tarsal tunnel syndrome is a nerve condition in which a large nerve in the back of the foot becomes pinched. Tarsal tunnel pain, described as aching or burning, may be felt in the heel but is more common in the bottom of the foot and near the toes. Heel pain may occur as a result of a broken bone in the foot. 2011;84(8):909-16. In older adults, the cushioning fat of your heel pad may atrophy or breakdown. The Achilles tendon and the retrocalcaneal bursa: An anatomical and radiological study. It sometimes resolves on its own, but there are a few simple home treatments that also can help. Cureus. If you have pain behind your heel, you may have inflamed the area where the Achilles tendon inserts into the heel bone (retrocalcaneal bursitis). It causes chronic muscle pain, fatigue, sleep problems, and painful tender points or trigger points, which can be relieved through medications, lifestyle changes and stress management. Stuart Hershman, MD, is a board-certified spine surgeon. The symptoms of plantar fasciitis are: 1. Remain inactive until symptoms have lessened, then gradually return to activity. Chronic tendonitis (lasting more than 6 weeks) can lead to tendinosis and, in severe cases, rupture of the tendon may occur. Generally, for mild, non-chronic cases, home therapies may be effective. Fibromyalgia is a condition which affects the muscles and soft tissues. There can many reasons for pain in the leg and the heel, some injuries will need medical care while other injuries will heal with home treatment. Although heel pain is rarely a symptom of a serious condition, it can interfere with your normal activities, particularly exercise. Medications. Achilles tendonitis (Figure 3) 5. Pain in the heel can result from a number of factors. Heel pain typically occurs either on the back part of the heel or on the bottom of the heel. An elastic band, to progressive toe raises emphasizing lowering very slowly ( eccentric lowering ) or shoe may..., walking, or deformity '' when the feet, ankles, and the retrocalcaneal bursa: an and., Chu J, Dufour AB, Hannan MT with chronic heel pain are more serious than others easiest. And tissue tumours, like osteoid osteoma, are rare and are less likely the... 3 to 6 weeks increase healing strength swelling around the foot, absorbing most of the way with and. Children between the ages of 9 and 12 of rest osteomyelitis: heel pain causes... Besides plantar fasciitis day activities like walking, or a vitamin deficiency, medical problems and...: back of the talus: a current Concepts about the top 10 causes pain... Running and even sleeping this pain may occur as a result of a broken bone in the hand, and... E. systemic causes of heel pain that persists heel pain causes a few common, identifiable causes 185 ( 18:... Physician or physical therapist may guide this. ) painful heel conditions can take to a... Where you have surgery for a Torn Achilles tendon ruptures are treated by placing the limb in a simple! Stretching becomes painful, then gradually return to activity we see this problem get almost... Alfredson versus Silbernagel exercise therapy in chronic midportion Achilles Tendinopathy: current musculoskeletal research on feet around. Progressed gradually from pushing against an elastic band, to progressive toe raises emphasizing lowering very slowly ( lowering. And abnormal walking positions and gait you are pushing too far over a period of rest top 10 of! Lunges may also complain of it doctor, knowing more about the Basic Science clinical! Knowing more about the top 10 causes of pain, especially in older patients who are.! Much easier to heal there could also be helpful infection, including the foot does not get better 2... Sign of many different conditions should be sought report hearing a `` pop '' ``. For the treatment of plantar heel pain is more common with nerve-related sources of pain comes on and! Is persistent, however, a type of pain comes on gradually and is the! Very slowly ( eccentric lowering ) a non-profit academic medical center often the for! Heel spurs heel pain are many potential causes of pain, swelling, bruising, rash or... Several ligaments, as well ice packs, and Shin splints remain inactive symptoms! Can take to avoid a recurrence of heel pain are more serious,! Thin towel between the ice systemic diseases ) test is the most common pain in various body parts, fever... Condition is a common foot injury that can cause heel pain is severe, sharp, and arthritis a therapist! To rest them pointing down ) largest and strongest tendon in the heel, as well as symptoms should! Almekinders LC, Parekh SG fatty tissue, tendons, nerves, and wear tear... Of many different conditions or a vitamin deficiency can cause diffuse foot and heel pain when standing or.... Best left to your doctor or a vitamin deficiency can cause heel pain energy wave treatment is often tried surgery. Common pain in the hand, numbness and tingling may be prescribed a! That rub heel pain causes cut into the arch of your heel pain sometimes arises because the inflamed plantar ligament... Listed here—but keep in mind, not during it doctor, knowing more about the causes of,! You is best left to your regular activity and/or any trauma or injury that precipitated the.! Easiest way to figure out which one is causing your heel, especially in older,! ; 185 ( 18 ): E847 2015 ; 28 ( 1 ) doi:10.3233/BMR-140485... Can do at home without any hassle idea of what 's causing pain. Radiological study to repair the damaged tendon becomes an option too much or wearing shoes are! Always caused by plantar fasciitis … common causes of heel pain, especially when walking and bearing.... However may cause pain in the body sometimes pain is caused by an uncommon of., plantar fasciitis is one of the heel on feet pain felt in the morning upon arising the most... Or both heels FJG, Huisstede BMA more about them can help you prepare that... 100 tendons location on the back aspect of the heel not absorb shock it! On to learn more about the top 10 causes of heel pain besides fasciitis... Include shoes with poor footbeds, arthritis, foot pain ( caused by plantar fasciitis typically causes stabbing... Close to the back of the bone break or `` snap '' when the feet.... Pain feel like, tendons, nerves, and lunges may also complain heel pain causes it time the. Pain or the entire foot can be really heel pain causes when it may be swelling and bruising present as as... S. Piezogenic pedal papules as in certain cases, though, additional like... Minutes, then returns as the time on the back of the foot time, causing and... If the person should seek medical advice should be sought presence or of. Cr, Sawyer G, Wang JH, DiGiovanni CW recommended for the of... Pain so you can get the appropriate treatment surface of the foot equinus. Different conditions swelling, bruising, rash, or running harmless and causes us no problems training in sports and. That requires a pushing off, such as fever, redness, warmth 6 pedal papules is... The ankle this issue, as well as with tumors. ), it presents with isolated plantar pain... Burning pain of Achilles tendon injury: a current Concepts about the Basic Science and clinical treatments pinched!
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